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Psychotherapy Advanced Practice Psychiatric Nurse
Week 1 Required Readings: Wheeler, K. (2022).: A how-to guide for evidence-based practice (3rd ed.). Springer. Chapter 1: The Nurse Psychotherapist and a Framework for Practice The difference between the biomedical model compared to the Holistic Model of Care PMHNPs embrace a holistic model of care with a focus on healing, in contrast to the cure-focused biomedical model. Biomedical Model: o Focuses on biological aspects of illness. o Prioritizes diagnosis and medical treatments such as medications or surgeries. o Often excludes emotional, social, and spiritual influences. Holistic Model: o Emphasizes treating the person as a whole. o Includes emotional well-being, social factors, spiritual health, and physical health. o Supports patient-centered approaches and long-term wellness. *Identify specific psychotherapy techniques to build and foster therapeutic relationships with clients/patients such as emotional connection, good listening skills o Active Listening : Demonstrating full attention to clients by paraphrasing and summarizing their concerns. o Emotional Connection : Establishing rapport through empathy and genuine understanding. o Demonstrating Empathy : Validating emotions to help clients feel seen and heard. o Fostering Trust : Maintaining confidentiality and consistency in interactions. *What does resilience mean? What are stabilization strategies? o Resilience: The term resilience refers to the ability of an individual, family, or community to cope with adversity and trauma, and adapt to challenges through individual physical, emotional, and spiritual attributes and access to cultural and social resources (adapted from SAMHSA, 2014). In fact, there is speculation that surviving a crisis can actually be a growth-promoting experience for some people. o Stabilization Strategies: Techniques like grounding exercises, mindfulness, and relaxation techniques; Aim to reduce emotional distress and ensure the client feels secure. Identify Peplau’s Roles
o Stranger : The nurse offers a welcoming environment to build initial rapport. o Resource : Acts as an information source for the patient’s needs and treatment. o Teacher : Provides education about mental health topics or coping strategies. o Counselor : Listens actively and provides emotional support. o Surrogate : Steps into roles that the patient cannot manage themselves temporarily. o Leader : Guides collaborative decision-making and helps set achievable goals. Maslow’s hierarchy of needs, what does self-actualization look like? o Maslow’s Hierarchy of Needs : Basic needs (e.g., safety, food) precede higher-level needs (e.g., self-actualization). o Self-Actualization : Represents the highest level of personal growth and fulfillment; Includes traits like creativity, independence, and striving to reach one’s full potential
o Mental Health : ACEs increase the likelihood of depression, anxiety, and PTSD. o Physical Health : Linked to chronic diseases like diabetes and heart disease due to prolonged stress. o Social Outcomes : May affect relationship-building and resilience in adulthood. Health Belief Model - The model includes several constructs: The Health Belief Model is used to explain and predict health behaviors. According to the Health Belief Model, a person’s belief about a perceived threat of illness combined with belief in the effectiveness of the recommended action predict the person’s willingness to change. The model includes several constructs: perceived seriousness, perceived susceptibility, perceived benefits of treatment, perceived barriers to treatment, cues to action, and self-efficacy. o Perceived susceptibility : clients must believe they are susceptible to the condition o Perceived severity : clients must believe the condition has serious consequences if left unattended o Perceived benefits : clients must believe that taking action reduces their susceptibility o Perceived barriers : clients must believe that the benefits of acting are greater than the barriers perceived o Cue to action : clients are exposed to something that causes them to act, such as an ad or discussion with a provider o Self-efficacy : clients feel they can succeed when performing an action Transtheoretical Model of Change - This theory includes several stages: The Transtheoretical Model of Change assumes that behavior changes take place over time and that people move through stages of decision-making to make changes to behavior. This theory includes several stages: precontemplation, contemplation, preparation, action, and maintenance. The PMHNP must recognize the client’s current stage of change to best help them move forward. o Precontemplation : Clients are not aware or interested in change [person smoking] o Contemplation : Clients begin thinking about change [person walking past a quit smoking ad] o Preparation : Clients plan for change [person circling a date on the calendar as a prep for quit date] o Action : Clients change old habits and gain new, healthier habits [person throwing cigarettes in the bin and exercising] o Maintenance : Clients continue with healthier behaviors [person as a fit runner] Required Readings: Wheeler, K. (2022). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer. Chapter 23: Reimbursement and Documentation What is Reimbursement Coding : o Clinical procedural terminology (CPT) codes are standardized codes used by medical professionals, including nurse practitioners, to communicate services completed to Medicare and other insurance companies for reimbursement. The American Medical Association (2021) maintains, revises, and publishes the CPT manual. o PMHNPs can bill for stand-alone psychotherapy using psychiatry specialty codes, but if the encounter includes diagnosing and/or prescribing medications, a medical evaluation and management (E/M) base code should be used with an add-on psychotherapy procedure code. Using an E/M code with an add-on will typically result in greater reimbursement than a stand-alone psychotherapy code. The PMHNP should ensure that documentation mirrors the billing codes selected. o The specific five-digit E/M code is selected based on the type of client, location of service, and level of service. o The American Psychological Association has developed psychotherapy specific codes. These codes are used for
psychotherapy services. The psychiatric mental health nurse practitioner (PMHNP) is in a unique position where both medical management and psychotherapy codes can both be billed for client encounters. Psychotherapy codes
Required Readings: Boland, R., & Verduin, M.L. (2022) Kaplan and Sadock's synopsis of psychiatry (12th ed.). Wolters Kluwer. Chapter 34: Transcultural Psychiatry, pp. 1047- *Concepts of migration, acculturation, acculturative stress o Migration : The process of relocating to a new country or culture. o Acculturation : Adapting to the dominant culture while retaining original cultural identity. o Acculturative Stress : Psychological stress from navigating cultural differences. Required Readings: Boland, R., & Verduin, M.L. (2022) Kaplan and Sadock's synopsis of psychiatry (12th ed.). Wolters Kluwer. Chapter 34: Culture-bound Syndromes, pp. 1052- *Culture-bound syndromes and their relationship to psychiatric disorders. o Disorders recognized within specific cultural contexts, such as "Ataque de nervios" : Seen in Latin cultures, often related to stress and family issues. Week 2 Required Readings: Wheeler, K. (2022). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer. Chapter 4: The Initial Contact and Maintaining the Frame *How can the therapeutic relationship be enhanced, what are three common elements included in the therapeutic relationship (Box 4.1) o Empathy, active listening, clear communication, and professional boundaries. o Box 4.1 : Three common elements—empathy, congruence, and unconditional positive regard. *What should be included in the initial contact? Box 4.2 SAFE-T, fees Practical arrangements, such as the location, frequency of sessions, and payment, are typically part of the initiation process. Although gathering information and establishing expectations for therapeutic interactions are early goals of the initiation phase, other needs, such as safety, may take priority. Interactions must be adjusted to fit the client's individual needs. Common elements of the frame include the process for contacting the provider, what to do in case of an emergency, adherence to a schedule, fees, confidentiality, and boundaries of the therapeutic relationship. Other elements of the frame may include minor details such as whether eating and drinking during the session are appropriate, whether session interruptions are allowed, whether phone calls between sessions are acceptable, and starting and stopping on time. Although a contract is not required to begin therapy, the best practice is to provide a written therapy contract detailing the terms of the therapeutic relationship, including scheduling, and missed appointments, fees, confidentiality, and termination.
*Evaluating Effective Therapeutic Communication Techniques Table 4. o Refer to Table 4.6 for examples like reflection, paraphrasing, and summarizing. *What are boundary violations o Actions that blur professional boundaries, such as dual relationships. *Describe paradoxical intervention. o Using unexpected approaches to change behavior, e.g., prescribing the symptom. How are progress notes verses process notes different? Process notes are a personal tool for the therapist to record thoughts, feelings, observations, or hypotheses during or immediately following the session. Process notes are private. Clients, other providers, and insurance companies may request access to process notes; however, the provider is not obligated to share them except in limited situations. Clients must provide authorization before the provider sharing process notes. Document therapist's observations and internal reflections; include the providers’ thoughts, verbatim notes. Progress notes contain the treatment plan: history, diagnosis, medication details, and progress summaries. Progress notes are considered a part of the medical record and may be shared, as appropriate, with other providers, insurance companies, and the client. Focus on treatment goals and outcomes; is more formal – Legal purposes and goal acquisition. Therapy Phases - Know each phase and what is most likely to occur in each phase o Initial: Establish trust and goals. o Working: Implement interventions. o Termination: Conclude therapy effectively. *Setting boundaries What are Grounds for termination o Goals Achieved o Therapist moves, patient moves o Patient unable to pay or insurance will not *Psychotherapy setting considerations- what might be in the office according to the client’s age
Documentation requirements include the use of a standard format of chief complaint, history of present illness, review of systems, past psychiatric history, mental status exam, diagnostic formulation, and treatment plan. Safety plans A collaboratively written safety plan should be created for any client identified to be at risk for self-harm. A safety plan includes a prioritized list of coping strategies and resources the client can use when thinking about suicide or self-harm. Common elements of the frame include o The process for contacting the provider, what to do in case of an emergency, adherence to a schedule, fees, confidentiality, and boundaries of the therapeutic relationship. o Other elements of the frame may include minor details such as whether eating and drinking during the session are appropriate, whether session interruptions are allowed, whether phone calls between sessions are acceptable, and starting and stopping on time. o Setting Boundaries & safeguarding rules of therapy. o Shared level of trust. o Safety always. o Legal components: Records may be shared during civil proceedings, such as for divorce or custody cases. Courts may subpoena records for criminal proceedings. Court-ordered counseling records may be shared with the court. o Protective factors: o Safety assessment: Many clients may also be at risk for other forms of self-harm; therefore, a safety assessment should be conducted in the initial session. The assessment should include questions regarding suicidal and homicidal thoughts and thoughts of self-harm. A collaboratively written safety plan should be created for any client identified to be at risk for self-harm. o Suicide contract: A no-suicide or no-harm contract is not a legal document but rather an agreement between the client and therapist about what the client should do if they become suicidal (Suicide.org, n.d.). A suicide contract involves a commitment by the client to not commit suicide. A suicide contract may not be effective in a crisis and is not a substitute for clinical judgment. The contract is only as beneficial as the therapeutic alliance. *Legal requirements of disclosure - Know the components/situations that require disclosure. For court-mandated clients, the provider may be required to share information with the court. For example, if a client is required to remain sober and attend therapy, the provider may be required to share if the client reports using substances. If the provider is required to share information with the court, they must frankly discuss the limits of confidentiality with the client. Required Readings: Wheeler, K. (2022). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer. Chapter 24: Termination and Outcome Evaluation *When to terminate the therapeutic relationship Appropriate when goals are met, or if the therapeutic relationship is no longer effective. For most clients, the length of therapy is not indefinite. The number of therapy sessions is often dependent on the type of therapy; for example, clients receiving cognitive behavioral therapy typically engage in 5-20 sessions (Mayo Clinic, n.d.). Discussion of therapy termination should begin at the initiation of therapy. Ideally, when goals have been met, the client and therapist mutually decide to terminate the therapy relationship; however, the client can choose to terminate non- court-ordered therapy at any time. Premature termination can prevent goal attainment and potentially worsen client outcomes.
Reasons for premature termination include the client's inability to afford therapy, feelings that therapy is no longer beneficial, or relocation out of the therapist's service area.
Usefulness in therapy Required Readings: Boland, R., & Verduin, M.L. (2022) Kaplan and Sadock's synopsis of psychiatry (12th ed.). Wolters Kluwer. Chapter 34: Contributions from the Behavioral and Social Sciences; Sigmund Freud: Founder of classic psychoanalysis, Tables 34- 10, 34-11, 34-12; Erik H. Erikson, Table 34-16; Other psychodynamic schools: Abraham Maslow Theorists and their theories Maslow’s hierarchy of needs provides a framework for understanding client motivation. If given a description of the theory, can you identify the theorist? Know the constructs /essential components/stages of the theories Know the focus of each discussed theory Abraham Maslow theorized that all individuals have the same basic needs. Maslow’s hierarchy of needs provides a framework for understanding client motivation. The first four levels of need in the hierarchy (physiological needs, safety, love and belonging, and esteem) are sometimes referred to as deficiency needs (D-needs). The longer D-needs are unmet, the more people are motivated to fulfill their needs and the more active the therapist must be in the relationship (Wheeler, 2022). Motivation decreases once D-needs are met. The highest level of need, self-actualization, is considered a growth or
being need (B-need) (McLeod, 2020). Once D-needs are met, clients can focus on self-actualization and personal growth.
bed after a sibling is born).
Hypochondria : exaggerating an illness arising from unacceptable feelings (e.g., anger and hostility are transformed into pain and somatic complaints). Introjection : internalizing the qualities of the other (e.g., identification with the aggressor through which the person becomes aggressive to gain control). Somatization : converting emotion into bodily symptoms (e.g., instead of getting angry, the person gets a headache). Splitting : inability to integrate positive with negative aspects of oneself and then projecting this onto other people or situations (e.g., a woman tells her husband she loves him one day and hates him the next day, even though nothing has changed to warrant this). Neurotic Defenses Displacement : shift of emotion from a person or object to one that is less distressing (e.g., instead of expressing anger at his boss, the man kicks his dog). Dissociation : avoiding emotional distress through an altered state of consciousness, such as fugue states or conversion reactions (e.g., a person loses several hours of time and does not remember what happened). Intellectualization : using intelligence to avoid intimacy and expression of disturbing feelings (e.g., a woman explains in great detail all the pluses of the new city where she is moving to assuage her anxiety about leaving a significant relationship). Rationalization : offering explanations in an attempt to explain behaviors or feelings that are unacceptable (e.g., after doing poorly on a test, the student believes the test or teacher is stupid). Reaction formation : transforming an unacceptable impulse into the opposite (e.g., a woman unexpectedly runs into someone she does not like on the street and is overly friendly). Repression : thought to be the basis of all other defenses and involves withholding from consciousness an idea or feeling that is unacceptable (e.g., the child cannot remember her anger or hitting her mother). Which ones are healthy defense mechanism Mature Defenses Sublimation : channeling unacceptable impulses through pursuing socially acceptable goals (e.g., a young man who is aggressive and impulsive pursues a career as a boxing coach). Suppression : consciously deciding to forget an unpleasant feeling (e.g., a woman is preoccupied with the illness of her father and decides to not worry about it because there is nothing, she can do about it). Altruism : using service to others and vicariously experiencing pleasure through doing good for others to avoid negative feelings about oneself (e.g., a young woman is a social activist). Humor : using comedy to express feelings and thoughts without discomfort (e.g., a person uses self-deprecating humor to put others at ease). *Peplau- Be able to provide an example for each of Pelau’s Nursing Roles Stranger : o Role: Greet the patient warmly and create a trusting, nonjudgmental environment. o Example: "Hello, my name is [Nurse's Name]. I’m here to help you feel comfortable and supported." Resource Person : o Role: Provide information or answers to specific questions. o Example: Explaining how medications work or outlining the steps in a treatment plan. Teacher : o Role: Educate the patient about mental health, coping mechanisms, or self-care strategies. o Example: Teaching a patient deep breathing techniques to manage anxiety. Counselor : o Role: Listen actively and help the patient process emotions or experiences. o Example: "It sounds like this situation has been very stressful for you. Let’s talk about how you’re feeling."
Psychotherapy interventions can be designed to target any or all areas of the dissociated memory or experience— behavior, relationships, beliefs, the body, images, and/or emotions—to facilitate healing and promote neurophysiological harmony through: o Therapeutic relationship o Bibliotherapy/role play o Case management o Cognitive behavioral therapy o Community resiliency model skills o Dialectical behavioral therapy o Education about RZ o Managing physiological arousal o Imagery o Container o Calm place o Mindfulness/meditation o Medication o Stress management/education o Provide safety
o Yoga/exercise
Supportive psychotherapy is psychodynamic in that it is based on a knowledge of the patient’s psychodynamics, which shapes the approach, but the goals of treatment differ considerably. Used for Stabilization, resource building, anxiety reduction, problem solving. (Example: Strategy #12: Ameliorate hopelessness) Use cognitive behavioral therapy, reframing, case management such as helping the person to obtain disability, housing, job, transportation, community resources. (Example: Strategy # 13: Focus on the here and now) Address primary issues: (1) safety, (2) therapy interfering behaviors, (3) future-foreclosing events or plans, (4) treatment noncompliance, (5) negative transference Expressive therapy Brief Psychodynamic Therapy BOX 5.1 General Principles for Conducting Brief Psychodynamic Psychotherapy (20-30) sessions •Establish a therapeutic alliance •Set a termination date (within 30 sessions) •Deal with initial resistances •Gather historical and other data
•What is the most important problem? Why now? What has been done so far? •What does the patient think caused the problem? What does the patient want from therapy? •Select the symptoms (focus) most amenable to treatment within the first three sessions •Define the precipitating event •Identify developmental issues and defenses to understand how to proceed •Share the case formulation with the patient •Enlist the patient as an active participant through a verbal contract •Use the most effective techniques to help the patient •Identify resistances or alliance ruptures, and address them with the patient •Be sensitive to how the past is influencing the present •Examine countertransference feelings •Give homework (optional) •Stress the need for continuing work Required Reading: Boland, R., & Verduin, M.L. (2022) Kaplan and Sadock's synopsis of psychiatry (12th ed.). Wolters Kluwer. Chapter 32: Attachment Theory, pp.1010- *Bowlby Boland ch 34, page 1011 Attachment Week 4 Required Reading: Wheeler, K. (2022). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer. Chapter 6: Humanistic-Existential Psychotherapy, pp. 289-312; 316- *Who are the humanistic-existential founders? •Humanism-Dominant themes: Happiness, spontaneity, creativity, actualization, holism, and goodness of the human spirit •Existentialism- focuses on personal choice and commitment, responsibility, and courage •Phenomenology lived experience as the source of knowledge The humanistic–existential approach has long served as a foundation for psychiatric nursing with its emphasis on holism, self-actualization, facilitative communication, and the therapeutic relationship. In undergraduate programs, psychiatric nursing students are commonly taught Abraham Maslow’s theory of human needs and Carl Rogers’s
